CMS Pub. 100-04, ch. 28, § 70.6.1.1

Coordination of Benefits (COB) Flat File Errors

(Rev. 3714, Issued: 02-03-17; Effective: 07-01-17; Implementation: 07-03-17)

Effective with the implementation of the Health Insurance Portability and Accountability Act (HIPAA) ASC

X12 837 5010 COB requirements, the BCRC will return the error codes shown in the chart below to all A/B

MACs and DME MACs whose flat file submissions lack structural elements necessary for the building of

outbound HIPAA compliant crossover claims.

The shared systems shall, in addition, make modifications to any “111” error tables that they maintain, in

accordance with the following charts, only in association with ASC X12 837 5010 COB flat files.

BCRC DETAILED ERROR REPORT “111” ERROR CRITERIA FOR 837 VERSION 5010

INSTITUTIONAL COB CLAIMS

Error

Code

Error Description Control

#

COBA

ID

Medicare

ID

CCN Loop

ID

Segment Element Content BHT

03

Reject

Level

100 No ST Segment NO NO NO NO NO YES NO NO NO HEAD

101 No BHT Segment YES NO NO NO NO YES NO NO NO HEAD

103 Missing 1000A

Records

YES NO NO NO YES YES NO NO YES HEAD

104 Missing 1000B

Records

YES NO NO NO YES YES NO NO YES HEAD

105 Invalid

1000A.NM109

YES NO NO NO YES YES YES YES YES HEAD

110 Invalid

1000B.NM103

YES NO NO NO YES YES YES YES YES HEAD

115 Invalid

1000B.NM109

YES YES NO NO YES YES YES YES YES HEAD

120 Multiple 1000A per

ST/SE

YES NO NO NO YES YES NO NO YES HEAD

125 Multiple 1000B per

ST/SE

YES NO NO NO YES YES NO NO YES HEAD

Error

Code

Error Description Control

#

COBA

ID

Medicare

ID

CCN Loop

ID

Segment Element Content BHT

03

Reject

Level

199 All 2000B Rejected YES YES NO NO YES YES NO NO YES HEAD

200 Missing 2000A YES YES NO NO YES YES NO NO YES PROV

201 Missing 2010AA YES YES NO NO YES YES NO NO YES PROV

210 Multiple 2010AA per

2000A

YES YES NO NO YES YES NO NO YES PROV

211 Multiple 2010AB per

2000A

YES YES NO NO YES YES NO NO YES PROV

212 Invalid presence of

2010AC per 2000A

YES YES NO NO YES YES NO NO YES PROV

300 Missing 2000B YES YES NO NO YES YES NO NO YES SUB

301 Missing 2010BA YES YES NO NO YES YES NO NO YES SUB

302 Missing 2010BB

Loop

YES YES YES NO YES YES NO NO YES SUB

305 Multiple 2010BB per

2000B

YES YES YES NO YES YES NO NO YES SUB

306 Multiple 2010BA per

2000B

YES YES YES NO YES YES NO NO YES SUB

310 2010BB.NM109 not

equal 1000B.NM109

YES YES YES NO YES YES YES YES YES SUB

Error

Code

Error Description Control

#

COBA

ID

Medicare

ID

CCN Loop

ID

Segment Element Content BHT

03

Reject

Level

320 2010BB.N3 not equal

spaces

YES YES YES NO YES YES YES YES YES SUB

321 2010BB.N4 not equal

spaces

YES YES YES NO YES YES YES YES YES SUB

351 More than 100 2300

per 2000B

YES YES YES NO YES YES NO NO YES SUB

355 2300 REF01 Equal

F5 Missing

YES YES YES NO YES YES NO NO YES SUB

356 2300 HI Invalid YES YES YES NO YES YES NO NO YES SUB

399 All 2300 Loops

Rejected

YES YES YES NO YES YES NO NO YES SUB

400 2010CA Found YES YES YES NO YES YES NO NO YES

500 2300 Not Found YES YES YES NO YES YES NO NO YES CLM

505 2320 Not Found YES YES YES NO YES YES NO NO YES CLM

506 # of 2320 Loops GT

10

YES YES YES YES YES YES NO NO YES CLM

507 2320 OI Not Found YES YES YES YES YES YES NO NO YES CLM

515 2400 Not Found YES YES YES YES YES YES NO NO YES CLM

Error

Code

Error Description Control

#

COBA

ID

Medicare

ID

CCN Loop

ID

Segment Element Content BHT

03

Reject

Level

520 # of 2400 Loops GT

999

YES YES YES YES YES YES NO NO YES CLM

575 2330A Not Found YES YES YES NO YES YES NO NO YES CLM

576 2330B Not Found YES YES YES NO YES YES NO NO YES CLM

580 2320.SBR01 not

equal P (must be at

least one “P”

segment)

YES YES YES NO YES YES YES YES YES CLM

581 2320.SBR Field

Invalid (SBR09 does

not equal MB when

Medicare is primary

in SBR01)

YES YES YES NO YES YES NO NO YES CLM

590 Multiple 2330A YES YES YES NO YES YES NO NO YES CLM

591 Multiple 2330B YES YES YES NO YES YES NO NO YES CLM

595 2330B.REF02 Equal YES YES YES YES YES YES YES YES YES CLM

596 2330B.NM109

Invalid COBA ID

(Not Used)

YES YES YES YES YES YES YES YES YES CLM

597 2330B REF not

found

YES YES YES YES YES YES YES YES YES CLM

Error

Code

Error Description Control

#

COBA

ID

Medicare

ID

CCN Loop

ID

Segment Element Content BHT

03

Reject

Level

598 2330B NM103 equals

spaces and invalid

COBA ID in 2330B

NM109

YES YES YES YES YES YES YES YES YES CLM

610 # of 2430 Loops

greater than 15

YES YES YES YES YES YES NO NO YES CLM

620 2430.SVD01 not

equal 1000A.NM109

YES YES YES YES YES YES YES NO YES CLM

999 SE Segment Missing YES YES NO NO NO YES NO NO YES HEAD

BCRC DETAILED ERROR REPORT “111” ERROR CRITERIA FOR PROFESSIONAL COB CLAIMS

Error

Code

Error Description Control

#

COBA

ID

Medicare

ID

CCN Loop

ID

Segment Element Content BHT

03

Reject

Level

100 No ST Segment NO NO NO NO NO YES NO NO NO HEAD

101 No BHT Segment YES NO NO NO NO YES NO NO NO HEAD

103 Missing 1000A

Records

YES NO NO NO YES YES NO NO YES HEAD

104 Missing 1000B

Records

YES NO NO NO YES YES NO NO YES HEAD

105 Invalid

1000A.NM109

YES NO NO NO YES YES YES YES YES HEAD

110 Invalid

1000B.NM103

YES NO NO NO YES YES YES YES YES HEAD

115 Invalid

1000B.NM109

YES YES NO NO YES YES YES YES YES HEAD

120 Multiple 1000A per

ST/SE

YES NO NO NO YES YES NO NO YES HEAD

125 Multiple 1000B per

ST/SE

YES NO NO NO YES YES NO NO YES HEAD

199 All 2000B Rejected YES YES NO NO YES YES NO NO YES HEAD

200 Missing 2000A YES YES NO NO YES YES NO NO YES PROV

Error

Code

Error Description Control

#

COBA

ID

Medicare

ID

CCN Loop

ID

Segment Element Content BHT

03

Reject

Level

201 Missing 2010AA YES YES NO NO YES YES NO NO YES PROV

210 Multiple 2010AA per

2000A

YES YES NO NO YES YES NO NO YES PROV

211 Multiple 2010AB per

2000A

YES YES NO NO YES YES NO NO YES PROV

212 Invalid presence of

2010AC per 2000A

YES YES NO NO YES YES NO NO YES PROV

300 Missing 2000B YES YES NO NO YES YES NO NO YES SUB

301 Missing 2010BA YES YES NO NO YES YES NO NO YES SUB

302 Missing 2010BB

Loop

YES YES YES NO YES YES NO NO YES SUB

305 Multiple 2010BB per

2000B

YES YES YES NO YES YES NO NO YES SUB

306 Multiple 2010BA per

2000B

YES YES YES NO YES YES NO NO YES SUB

310 2010BB.NM109 not

equal 1000B.NM109

YES YES YES NO YES YES YES YES YES SUB

320 2010BB.N3 not equal

spaces

YES YES YES NO YES YES YES YES YES SUB

Error

Code

Error Description Control

#

COBA

ID

Medicare

ID

CCN Loop

ID

Segment Element Content BHT

03

Reject

Level

321 2010BB.N4 not equal

spaces

YES YES YES NO YES YES YES YES YES SUB

351 More than 100 2300

per 2000B

YES YES YES NO YES YES NO NO YES SUB

355 2300 REF01 Equal

F5 Missing

YES YES YES NO YES YES NO NO YES SUB

356 2300 HI Invalid YES YES YES NO YES YES NO NO YES SUB

399 All 2300 Loops

Rejected

YES YES YES NO YES YES NO NO YES SUB

400 2010CA Found YES YES YES NO YES YES NO NO YES

500 2300 Not Found YES YES YES NO YES YES NO NO YES CLM

505 2320 Not Found YES YES YES NO YES YES NO NO YES CLM

506 # of 2320 Loops GT

10

YES YES YES YES YES YES NO NO YES CLM

507 2320 OI Not Found YES YES YES YES YES YES NO NO YES CLM

515 2400 Not Found YES YES YES YES YES YES NO NO YES CLM

520 # of 2400 Loops GT

50

YES YES YES YES YES YES NO NO YES CLM

575 2330A Not Found YES YES YES NO YES YES NO NO YES CLM

Error

Code

Error Description Control

#

COBA

ID

Medicare

ID

CCN Loop

ID

Segment Element Content BHT

03

Reject

Level

576 2330B Not Found YES YES YES NO YES YES NO NO YES CLM

580 2320.SBR01 not

Equal P (must be at

least one “P”

segment)

YES YES YES NO YES YES YES YES YES CLM

581 2320.SBR Field

Invalid (SBR09 does

not equal MB when

Medicare is primary

in SBR01)

YES YES YES NO YES YES NO NO YES CLM

590 Multiple 2330A YES YES YES NO YES YES NO NO YES CLM

591 Multiple 2330B YES YES YES NO YES YES NO NO YES CLM

595 2330B.REF02 Equal YES YES YES YES YES YES YES YES YES CLM

596 2330B.NM109

Invalid COBA ID

(Not Used)

YES YES YES YES YES YES YES YES YES CLM

597 2330B REF not

found

YES YES YES YES YES YES YES YES YES CLM

598 2330B NM103 equals

spaces and invalid

COBA ID in 2330B

NM109

YES YES YES YES YES YES YES YES YES CLM

Error

Code

Error Description Control

#

COBA

ID

Medicare

ID

CCN Loop

ID

Segment Element Content BHT

03

Reject

Level

610 # of 2430 Loops

greater than 15

YES YES YES YES YES YES NO NO YES CLM

620 2430.SVD01 not

equal 1000A.NM109

YES YES YES YES YES YES YES NO YES CLM

999 SE Segment Missing YES YES NO NO NO YES NO NO YES HEAD